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llep[nfrom Surface-owrl2S2S_prtl.pdt - - _ � -- - -- - p: ww'wsM et on r <br /> • File Original with DWR Slate of California ___ __ DWR Use O1J�DG Not Fill In___ <br /> Page i of Well Completion Report __-----___-_-- -_ -_ ,.----- <br /> Refar to lasmrodan Pamerilel I <br /> ,. - St-ata Well,N'umber/S .Number/Site Owner's Well Number Vt1 W '3 No. iJ - I I ! W <br /> Date Work Began 3—(9-/3 Date Work Ended 3-/y-/3 \\ Latitude Longitude___ --- <br /> Local Permit Agency SAtj lo.4 Cew<.t 6,--vN7y' 7fd. ll ll vw7Ect #10L-AlLdeT <br /> Permit Number (.097- Permit Date PA R-L,.I L( 2,043 APN/rFIS/Olher <br /> Geologic Log Well Owner <br /> OrientationVgfltca Horizontal Angle Specify Name GLpj f ,17p,2,16S 1-1oL6 e r ImL - <br /> Drilling Method A-j,6 fl Drilling Fluid <br /> Depth from Surface Description Mailing Address $-Gte$ LBT r=�', S✓'-`�: I:S G._ <br /> Feet to Feet Describe material.grain size color,etc city 23ALL-rr-3 Slate TX zip <br /> Well Location <br /> p <br /> ID` ;1h I 1 w,l- Address jg&� Ir,t Gbfl;�Te<L s.%l�`i <br /> c.�f4R,u 8oX <br /> City -�i OLKTG_-I Gq County Sr"! TUAf+'u Ir`( <br /> Latitude N Longitude W <br /> DthMiT CDao. Min. sec. Deo Min See. <br /> j i3e 2c. rtUc.! Dalum Decimal Lat.!l�tic i,.I-, Decimal Long.b'j2GZ8$. . <br /> j APN Book Page Parcel <br /> Township Range Section <br /> i,rlL. :A N r, Location Sketch Activit <br /> ISkelCh must be drawn by hand after form isprinted.) New Well <br /> North Modification/Repair <br /> i- >c Deepen <br /> Other <br /> `Destroy' <br /> r - I�-ff.y -rnure.aed m.mdau <br /> j \ - j orre.r-GEOLOGIC l00' <br /> 7-""`'v r�2 Planned Uses <br /> �pfLrv.L <br /> vn-t- = au" �(. IC tt16S A1rIL Water SuPPIY <br /> j to 24 0 1 '2hS prEr r _ Domestic Public <br /> 3 Lt°,t/��;c w' Irrigation Industrial <br /> Cathodic Protection <br /> Dewatering <br /> Heat Exchange <br /> Injection <br /> M� Monitoring <br /> Remediation <br /> Sparging <br /> South Test Well <br /> Ilmarot.erdc:moe enmr<or r.11 earn mx.,w�wlrq.,mrem Vapor Extraction <br /> ,,em and eaevi u:.mmlorep.o.,nna.:serf Other <br /> L{, WIT(( [d NTeYrtTS .Itc PNmMmaonN and.em Iola. <br /> - (1lo-Y�rd vc✓� <br /> i <br /> atLC tntG t trN /6 " LI06YK- , Water Level and Yield of Completed Well <br /> i tn;0 .7 ` PeS !n%N a/.:PT Depth to first water (Feel below surface) <br /> Depth to Sialic <br /> C.c-n'vrvry * A A(A-srrrL,zl !,I (r r 1 %0 5'QAOG. Water Level (Feel) Date Measured <br /> Total Depth of Boring Z� Feet Bus Estimated Yield' (GPM) Test Type <br /> Test Length (Hours) Total Drawdown (Feet) <br /> Total Depth of Completed Well "Z��, OFeel g6 •Ma not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type If Any Surface FIII Description <br /> Feet to Feet Inches Inches (Inches Inches Feet to Feet <br /> Attachments Certification Statement <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram Name . <br /> Peraon.Fmn or Corporation <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses n^,,, w �A�d�dress I cry stale F- zip <br /> Other Signed �'"'N:�trY� QMXut0 j, y � <br /> NE1legational inlarmotion.it it ekisis. G67 Llpens t er We Contractor Dale Signed C-57 License Nd h1I 1:05 PI A <br /> DWR 188 REV,11206 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />